CEN18LA381

NTSB accident investigation · Piper PA28 · Pagosa Springs, CO · September 19, 2018

Accident · No injuriesLimited investigationFinal report
Date
September 19, 2018, 10:00 local (16:00 UTC)
Place
Pagosa Springs, CO
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N8003WPiper PA28
Defining event
Maneuvering: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20180919013859A
Case key
98322

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The student pilot's mismanagement of the fuel selector valve during the simulated forced landing demonstration and the flight instructor's inadequate supervision to ensure the fuel selector was properly set, which resulted in a loss of engine power and subsequent forced landing on unsuitable terrain.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-28-180: 32 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Student/instructed pilotPiper PA-28-180: 16 casesAll aircraft: 1,391 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotPiper PA-28-180: 6 casesAll aircraft: 200 casesProbable cause
Object/animal/substance: fence/fence postEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-180: 6 casesAll aircraft: 313 cases
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-180: 2 casesAll aircraft: 442 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airline transport pilot rated flight instructor was introducing engine failure emergency procedures to the student pilot. Emergency procedures were reviewed inflight. The flight instructor then reduced the engine power to idle to simulate a loss of engine power. The student pilot conducted the emergency procedures on the left side of the cockpit that included switching the fuel tank selector position from right to left. The engine sputtered when the flight instructor subsequently added power to go around about 600 ft above the ground. The engine sputtered. Emergency procedures were reviewed again and the fuel pressure indication was zero. The flight instructor subsequently performed a forced landing where the airplane impacted fencing and ditches and came to rest in a field. Following the accident, the flight instructor noticed the fuel selector valve was about 1.5 to 2 inches between the left detent and off positions. No preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation were reported by the flight instructor and the engine was operational during a subsequent examination of the accident airplane at the accident site. It is likely the student pilot, while conducting the emergency procedure, mismanaged the positioning of the fuel selector valve. While the student pilot was conducting the emergency procedure, the flight instructor did not adequately supervise the student pilot to ensure the fuel selector valve was properly set to the correct position.

Factual narrative

On September 19, 2018, about 1000 mountain daylight time, a Piper PA28 180 airplane, N8003W, impacted fencing and terrain during a forced landing near Pagosa Springs, Colorado, following an inflight loss of engine power. The airline transport pilot rated flight instructor and the student pilot were uninjured. The airplane sustained substantial damage during the impact with fencing. The airplane was registered to and operated by San Juan Flyers Inc. as a Title 14 Code of Federal Regulations Part 91 instructional flight. Day visual meteorological conditions prevailed in the area about the time of the accident, and the flight was not operated on a flight plan. The local flight originated from the Stevens Field Airport, near Pagosa Springs, Colorado, about 0900.According to the flight instructor's accident report, the flight instructor was introducing engine failure emergency procedures to the student pilot. Emergency procedures were reviewed inflight, the instructor located a landing spot, and pulled the throttle to idle to simulate a loss of engine power. The student pilot conducted the emergency procedures on the left side of the cockpit that included switching the fuel tank selector position from right to left, verifying the primer was in and locked, turning on the fuel pump, checking magneto operation, and turning the carburetor heat on. The flight instructor subsequently added power to go around about 600 ft above the ground. The engine sputtered. Emergency procedures were reviewed again and the flight instructor noticed that the fuel pressure indication was zero. The flight instructor did not check the fuel selector nor could the selector be seen due to its location. The flight instructor subsequently performed a forced landing during which the airplane impacted fencing and ditches before coming to rest in a field. Following the accident, the flight instructor observed the fuel selector valve was about 1.5 to 2 inches between the left detent and off positions. Subsequent to the accident, a Federal Aviation Administration inspector examined the accident airplane at the accident site. The airplane's engine was started, and the engine was operational. The flight instructor reported no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation and had a safety recommendation to double check the fuel selector valve position during the forced landing demonstration.

Aircraft

Registration
N8003W
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-2063
Built
1964
Airframe hours
5,125
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
San Juan Flyers Inc
Registered owner
San Juan Flyers Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 18, 2018
Departed
PSO · Pagosa Springs, CO
Destination
PSO · Pagosa Springs, CO
Airport
PSO · Stevens Field
Equipment
Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
Lap only
Flight hours
10,000 total · 500 in this make and model · 9,800 as pilot in command · 54 in the last 90 days · 11 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
62
Injuries
None
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
3.4 total · 3.4 in this make and model · 3.4 in the last 90 days · 3.4 in the last 30 days · 0.6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 6 knots
Visibility
10 statute miles
Temperature
70 °F, dew point 32 °F
Altimeter
30.21 inHg
Observed at
KPSO, 5 nm away

Docket · 3

The files NTSB released with the investigation on October 18, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.